Fill and Sign the New York Guardian Form

SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF ____________________ Proceeding for the Appointment of a Permanent Guardian of the Person and Estate of _____________________ An Adult (Name of Respondent) Family File No._________ TO THE FAMILY COURT: AFFIDAVIT (CERTIFICATION) OF EXAMINING PHYSICIAN OR LICENSED PSYCHOLOGIST File No. _______________________________ Pursuant to SCPA Article 17-A STATE OF NEW YORK ) COUNTY OF________________) ss.: I, ____________________________ (Name of Physician or Licensed Psychologist) , Physician Licensed Psychologist, being duly sworn, deposes and says: 1. My license number is: _____________________________________________. 2. My offices are located at ______________________________________________________ ______________________ (street address, city, county, state, zip code) . 3. My professional knowledge and/or background in the care and treatment of persons with mental retardation developmental disabilities is as follows: _________________________ ________________________________________________________________________ 4. I have examined the Respondent __________________________ (Name of Respondent) on _________________________ (dates) . I have performed the following tests or evaluations of the Respondent . (Set forth in detail the names of tests and/or evaluations, dates performed and results.) ______________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________. I have reviewed the following tests or evaluations performed on Respondent . (Set forth in detail the names of tests and/or evaluations, dates performed, results and names of doctors who performed the tests and/or evaluations.) ______________________________ ____________________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________. 5. The mental and physical condition of the Respondent is as follows: (Describe in detail.) ( Include only the appropriate diagnosis) _________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. Mentally Retarded. Based upon the foregoing, it is my conclusion the Respondent is mentally retarded and in my opinion incapable of managing himself and/or his affairs by reason of mental retardation. The nature and degree of the mental retardation is as follows: (Describe) ____________________________________________________________________________ ____________________________________________________________________________ 7. Developmentally Disabled. Based upon the foregoing, it is my conclusion that the Respondent is developmentally disabled and in my opinion he has an impaired ability to understand and appreciate the nature and consequences of decisions, which results in Respondent being incapable of managing himself and/or his affairs by reason of developmental disability, and whose disability is attributable to: A. Cerebral palsy, which originated before the Respondent attained the age of twenty-two . (Describe, in detail, the nature, degree and origin of the disability.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ B. Epilepsy, which originated before the Respondent attained the age of twenty- two. (Describe, in detail, the nature, degree and origin of the disability). ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ C. Neurological impairment, which originated before the Respondent attained the age of twenty-two. ( Describe, in detail, the nature, degree and origin of the disability.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ D. Autism, which originated before the Respondent attained the age of twenty-two. (Describe, in detail, the nature, degree and origin of the disability.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ E. Traumatic head injury. (Describe, in detail, the nature, degree and origin of the disability.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ F. A condition, which originated before the Respondent attained the age of twenty- two, found to be closely related to mental retardation, because such condition results in similar impairment of general intellectual functioning or adaptive behavior to that of mentally retarded persons. (Describe, in detail, the nature, degree and origin of the disability.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ G. Dyslexia resulting from a disability described in subdivision (a) through (f) or mental retardation which condition originated before the Respondent attained the age of twenty-two. ( Describe in detail the nature, degree and origin of the disability or mental retardation.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 8. The condition of the Respondent is permanent in nature or likely to continue indefinitely. OR The condition of the Respondent is not permanent in nature nor likely to continue indefinitely. 9. There are no circumstances warranting Respondent’s nonappearance at the hearing required by the court. Respondent’s presence at the hearing should be dispensed with because he is medically incapable of being present to the extent that attendance is likely to result in physical harm to the Respondent . ( Explain in detail.) _________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ OR 10. Respondent’s presence at the hearing should be dispensed with for the following reasons: (Set forth facts and circumstances which would result in the court finding that the Respondent ’s presence at the hearing would not be in his/her best interest.) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ OR 11. Based upon the foregoing, it is my conclusion that the Respondent is not capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life-sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law. OR 12. Based upon the foregoing, it is my conclusion that the Respondent is capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law. OR 13. Based upon the foregoing, it is my conclusion that the Respondent has a developmental disability, as defined in Section 1.03 of the Mental Hygiene Law, which includes mental retardation, or results in a similar impairment of general intellectual functioning or adaptive behavior so that such person is incapable of managing himself or herself, and/or his or her affairs by reason of such developmental disability, and that the Respondent is not capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life-sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law. Based upon the foregoing, it is my conclusion that the Respondent is capable of understanding and appreciating the nature and consequences of health care decisions, including the benefits and risks of and alternatives to any proposed health care, and of reaching an informed decision in order to promote his own well being. A health care decision may include a decision to withhold or withdraw life sustaining treatment as defined in subdivision (e) of Section 81.29 of the Mental Hygiene Law. _______________________________________ Signature of Physician/Licensed Psychologist _______________________________________ Print Name Sworn to before me this_____ day of ____________, 20____. ____________________________________________ Notary Public Commission Expires:_______________________ (Affix Notary Stamp or Seal)